Perioperative Management of Antithrombotic Therapy

Introduction to Perioperative Aspirin Therapy

Preoperative aspirin reduces operative morbidity and mortality in cardiac surgery patients, as suggested by the American Heart Association 1
The American Heart Association recommends that CABG can be performed safely in patients on aspirin therapy with only a modest increase in bleeding risk 1

Aspirin can be continued in the perioperative period without increased risk of major bleeding for patients with cardiac risk factors on low-dose aspirin alone, as supported by the American Urological Association and the American College of Chest Physicians, with a strength of evidence level of 2B 2
For patients at moderate to high risk for cardiovascular events, the American College of Chest Physicians recommends continuing aspirin throughout the perioperative period, including those with recent coronary stents, history of myocardial infarction, or high ASCVD risk, with a strength of evidence level of 1B 3
For patients at low risk for cardiovascular events, the American College of Chest Physicians recommends stopping aspirin 7-10 days before surgery to allow for complete restoration of platelet function, with a strength of evidence level of 2B 4, 3

Not distinguishing between aspirin and other antiplatelet agents is crucial, as unlike aspirin, other agents such as clopidogrel and ticagrelor should be discontinued for at least 5 days before elective surgery, and prasugrel for at least 7 days 1
The following table summarizes the recommended discontinuation times for antithrombotic medications before surgery:

Medication	Discontinuation Time
Aspirin	Not recommended for discontinuation in most cases, but may be stopped 7-10 days before high-bleeding-risk procedures
Clopidogrel	5 days before elective surgery
Ticagrelor	3-5 days before elective surgery
Prasugrel	7 days before elective surgery
Apixaban, Dabigatran, Rivaroxaban	2 days before low bleeding risk procedures, 3-5 days before high bleeding risk procedures
Warfarin	5 days before elective surgery, with INR check (<1.5 is safe for surgery)

Dual antiplatelet therapy (aspirin plus clopidogrel, prasugrel, or ticagrelor) withdrawal should not occur before urological procedures within 12 months of drug-eluting stent placement or within 3 months of bare metal stent placement, as recommended by the American Urological Association, with a strength of evidence level of 1B 2

For patients on Apixaban, discontinuation is recommended at least 3-5 days before the procedure, as recommended by the American Society of Anesthesiologists and the American Urological Association, with a strength of evidence level of 1B 5, 2
For patients on Dabigatran, discontinuation recommendations vary based on creatinine clearance (CrCl): for CrCl >50 mL/min, stop 4 days before procedure, and for CrCl 30-50 mL/min, stop 5 days before procedure, as suggested by the American Society of Anesthesiologists and the American Urological Association, with a strength of evidence level of 1B 5, 2
Warfarin should be discontinued 5 days before elective surgery, with INR check (<1.5 is safe for surgery) 6

The American College of Cardiology recommends that beta blocker therapy should be continued throughout the perioperative period in patients who have been on them chronically (Class I recommendation, Level of Evidence B) 7, 8
Continuing beta blockers reduces the risk of perioperative cardiac events in patients with a history of myocardial infarction (MI) 8
Abrupt withdrawal of long-term beta blockers is harmful and can increase the risk of cardiac events, including myocardial ischemia, MI, and mortality 8

Aspirin should be restarted within 24-48 hours after surgery once adequate hemostasis is achieved, as recommended by the American College of Chest Physicians and other authorities, with a strength of evidence level of 1B 9, 3
Warfarin should be resumed 1-2 days after surgery depending on hemostatic status, as suggested by the European Heart Journal, with a strength of evidence level of 2B 10
Antiplatelet agents should be resumed within 24 hours after surgery if hemostasis is adequate, as recommended by the American College of Chest Physicians, with a strength of evidence level of 1B 4
Unfractionated Heparin (UFH) should be resumed at least 24 hours after the procedure, as recommended by the American College of Chest Physicians, with a strength of evidence level of 1B 6
Low Molecular Weight Heparin (LMWH) should be resumed at least 24 hours after low-to-moderate-bleeding-risk procedures and 48-72 hours after high-bleeding-risk procedures, according to the American College of Chest Physicians, with a strength of evidence level of 1B 6

A multidisciplinary approach involving cardiology expertise is essential when urgent urological procedures are required, as recommended by the American Urological Association, with a strength of evidence level of 1B 2
A multidisciplinary team approach, involving cardiologist, surgeon, anesthesiologist, and hematologist, is strongly recommended for patients with coronary stents or recent acute coronary syndrome, as recommended by the American Heart Association, with a strength of evidence level of 1B 11, 12
Patient-specific factors such as age, weight, and concomitant medications that may affect drug clearance should be considered, as recommended by the American Society of Anesthesiologists, with a strength of evidence level of 1B 5
Drug interactions that may increase anticoagulant plasma concentrations should be checked, such as P-glycoprotein inhibitors for all DOACs and cytochrome CYP3A4 inhibitors for xabans, as advised by the American Society of Anesthesiologists, with a strength of evidence level of 1B 5